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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($150) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION Q <br /> j <br /> Property Owner Name r 1 / Property Legal Description <br /> M� 1, � Q J� V 6rn GL H I/4 1/4, 01N,R W <br /> Property Owner's Mailin Address Lot Number Block Number <br /> 12 �� X,57_- V_, &k— <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> (_71S_ <br /> T pe of Building: (Check one)❑ State-Own ❑City Nearest R ad <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 9 ❑Village�"rac� t^ <br /> Public own of Fire Number <br /> Public Building/Land Use: [Explain the use/purpose for this permit.(i.e., Parcel Tax Number(s) <br /> campground,festival,recreation/entertainment event etc.)] <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> �POWTS ReconnectionCounty El Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> POWTS Repair # gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both ❑as appropriate.) <br /> ❑ I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,the undersigned,assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/O er's e( t) Plumb 's/Owner's Si Lure: MP/MPRSW No.: Business Phone Number: <br /> XM4 az7.7jKyr 3 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuing Agent Signature <br /> Approved ❑Owner Given Initial AdverseI50o 6 _i <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />